Wiki prior authorization

[Slraheb]

Hi, Can anyone tell me the best way to appeal a claim that required prior auth but one was not obtained because there was no time, the provider felt that the patient required a surgery that was more extensive than previously thought because of damage that was not seen until the patient was in surgery, that would have required the provider to stitch the patient back up and then subject her to another surgery just to get the prior authorization

 

[julieordway]

I have had this occur as well. Unfortunately it happens from time to time and requires immediate appeal to get paid. I always include a cover letter to the payor explaining the situation and that it was beyond your control to obtain a pre-auth due to unforseen circumstances discovered intra-operatively. State your case, and include all pertinent medical records, office notes, etc. Include a copy of the denial. Try with a reconsideration first which will probably get denied, then submit a first level appeal. Good Luck! This may help: https://content.naic.org/sites/default/files/consumer-health-insurance-appeal-denied-claims.pdf

 

[Slraheb]

I have had this occur as well. Unfortunately it happens from time to time and requires immediate appeal to get paid. I always include a cover letter to the payor explaining the situation and that it was beyond your control to obtain a pre-auth due to unforseen circumstances discovered intra-operatively. State your case, and include all pertinent medical records, office notes, etc. Include a copy of the denial. Try with a reconsideration first which will probably get denied, then submit a first level appeal. Good Luck! This may help: https://content.naic.org/sites/default/files/consumer-health-insurance-appeal-denied-claims.pdf

Thank you, I have tried appealing it a couple of times and they are still denying it, but I'm not giving up

 

[julieordway]

Good!!! Don't give up I've had claims that I have disputed with insurance plans for 6 months to a year and had a positive outcome!

 

[trarut]

I agree...don't give up. It sometimes takes a couple levels of appeal to get an actual reviewer to look at it. Remember too that you're establishing medical necessity for the service as the basis for why they should overturn the denial.

I would also find out what your payer contract states. Some contracts specifically state the provider has no appeal rights for denials due to no authorization. If that's the case, you're going to be spinning your wheels with that payer. The advantage to pursuing an appeal until you've exhausted your options is that it gives your leadership data for the next contract negotiation.